# Carotid Endarterectomy With Stent Explantation for In-Stent Restenosis in Two Patients and Review of the Literature

## TL;DR

This paper presents two successful cases of surgically removing carotid artery stents to treat restenosis, suggesting surgery may be safer and more durable than repeat procedures.

## Contribution

The paper introduces carotid endarterectomy with stent explantation as a novel treatment for in-stent restenosis, supported by two successful clinical cases.

## Key findings

- Two patients with severe carotid in-stent restenosis were successfully treated with surgical stent removal and patch angioplasty.
- Both patients maintained durable patency and experienced no neurological or cardiovascular complications.
- Surgical stent explantation may offer superior long-term outcomes compared to repeat endovascular interventions.

## Abstract

Carotid artery stenting (CAS) is a well-established alternative to carotid endarterectomy (CEA) for the treatment of carotid artery stenosis, particularly in patients at high surgical risk. However, in-stent restenosis (ISR) remains a notable long-term complication, occurring in up to 20% of patients within five years. The optimal management strategy for ISR remains unclear, as endovascular reintervention carries a significant risk of recurrence, and evidence supporting surgical explantation is limited.

We present two patients who developed severe carotid ISR and were successfully treated with CEA and complete stent explantation followed by bovine pericardial patch angioplasty. The first patient, an 84-year-old woman with bilateral carotid disease and a history of left carotid stenting, developed 90% restenosis at surveillance and underwent staged bilateral carotid revascularization with durable patency at three-year follow-up. The second patient, a 70-year-old man, presented with acute visual loss and imaging demonstrating near-occlusive thrombosis within a previously placed carotid stent. He underwent urgent surgical stent removal and patch angioplasty, achieving full recovery and maintaining patency at one year. Neither patient experienced perioperative neurological or cardiovascular complications.

These cases highlight the feasibility and safety of surgical stent explantation in the management of carotid ISR. Compared with repeat endovascular interventions, surgical removal directly addresses the underlying mechanical and neointimal causes of restenosis and may provide superior long-term durability in appropriately selected patients.

CEA with stent explantation represents an effective treatment option for ISR, particularly when endovascular options are limited by calcification, thrombus, or mechanical failure. Larger prospective studies are needed to establish patient selection criteria and optimize management strategies for this challenging clinical scenario.